FIFA Medical

Concussion Protocol

SUSPECT AND PROTECT

#SuspectAndProtect

TABLE OF CONTENTS
Definition and classification of concussion 2

Management of concussion  2

Baseline examination 3

Diagnosis and management in first 72 hours after head injury  3

Observation and recognition (Phase 1) 4

Emergency management and red flags for referral to hospital 5

Initial (on-pitch) examination of head injuries (Phase 2) 7

Off-pitch examination (Phase 3) 9

Quiet-area examination and treatment (Phase 4) 10

Observation and serial re-examination until departure (Phase 5) 10

Observation for 24 hours after head injury (Phase 6) 11

Re-evaluation between 18 and 72 hours after head injury (Phase 7) 12

Graduated Return-to-Football Programme (Phase 8) 12

Summary 15

References 16

FIFA Medical Concussion Protocol

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Head injuries can result in substantially different outcomes, ranging from no detectable effect to
transient functional impairments or life-threatening structural lesions. In high-level international
football tournaments, one head injury occurs every third match on average. This makes the
immediate diagnosis of a head injury and determination of its severity, whether on or off the
pitch, an essential skill for team physicians. Both elements can be challenging because clinical
signs of a brain injury do not necessarily present immediately, but rather can develop over several
minutes, hours or even days after the incident. Therefore, FIFA provides a standardised approach
to support team physicians in their decision as to whether a player should be allowed to continue
to play or should be removed from play after a head injury. If there is a SUSPICION of a concussive
injury at any stage, you should remove the player from the match or training session and assess
and treat them appropriately, as described in the following protocol.

Definition and classification of concussion

Concussion is defined as a traumatic brain injury induced by biomechanical forces.

Several common features may be utilised in clinically defining the nature of a concussive head
injury. These include the following:

• A sports-related concussion may be caused either by a direct blow to the head, face or neck
or by a blow to another part of the body with an impulsive force transmitted to the head.
• A sports-related concussion typically results in the rapid onset of short-lived impairment
of neurological function, which resolves spontaneously. However, in some cases, signs and
symptoms evolve over a number of minutes to hours.
• A sports-related concussion may result in neuropathological changes, but the acute clinical
signs and symptoms largely reflect a functional disturbance rather than a structural injury
and, as such, no abnormality is seen in standard structural neuroimaging studies.
• A sports-related concussion results in a range of clinical signs and symptoms that may or
may not involve loss of consciousness. The resolution of the clinical and cognitive features
typically follows a sequential course. However, in some cases, symptoms may be prolonged.

For a diagnosis of concussion, the clinical signs and symptoms should not be explainable by
drug, alcohol or medication use, other injuries (such as cervical injuries, peripheral vestibular
dysfunction, etc.) or other comorbidities (e.g. psychological factors or coexisting medical
conditions).

The evaluation after a head injury always includes an examination of associated structures, i.e.
the neck and labyrinth, since symptoms alone cannot distinguish physiologic concussion from
cervical/vestibular injury.

Management of concussion

There are several actions that can be performed prior to a concussion that will improve the
management of a concussed player, such as baseline examinations and the implementation of a
structured plan for post-concussion management.
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Baseline examination

A baseline examination refers to a concussion assessment performed at a time when a player

has not recently had a concussion incident (e.g. pre-season). The baseline examination provides
valuable information for both the diagnosis and management of head injuries. Results from
the baseline examination can be helpful to compare signs and symptoms following a potential
concussion incident and assess the level of impairment in comparison to what is normal for the
individual player. They can also be instrumental in the decision-making process with respect
to the return to football. The baseline testing results are not useful for the removal-from-play
decision.

FIFA recommends using the newest version of the Sport Concussion Assessment Tool (SCAT,
currently version 5) for baseline examinations. The SCAT is the most widely used sideline
assessment tool internationally and provides a battery of tests to assess several aspects of
brain function that are typically impaired in concussion. It measures consciousness, orientation,
neurocognitive function, self-reported symptoms and postural stability. It further includes a
section for acute concussion evaluation, taking note of observable signs of concussion, including
red flags, the Glasgow Coma Scale and cervical spine function, and a neurological screening
examination. The SCAT should take a minimum of ten minutes to complete. It has a sensitivity of
0.83-0.96 and a specificity of 0.81-0.91.

Diagnosis and management in first 72 hours after head injury

An eight-phase, systematic approach is recommended in the first 72 hours after a head injury
in high- level football, starting with the initial examination and continuing with diagnosis and
management:

Phase 1: Observation and recognition

Phase 2: Initial (on-pitch) examination
Phases 3-4: Off-pitch/quiet-area examination
Phases 5-7: Post-match examinations and observation
Phase 8: Graduated Return-to-Football Programme

Notably, this procedure is the sole responsibility of the team physician.

The purpose of the on-pitch assessment is to identify clinical signs, symptoms or mechanisms that
require removal from play for a more detailed examination. If there are signs or symptoms of
damage to the brain, or a concussive injury is suspected despite the absence of signs or symptoms,
the doctor/therapist should remove the player from the pitch for a more detailed examination
(using a concussion substitute if available/required). Due to the potential severe neurological
FIFA Medical Concussion Protocol

consequences of a head injury, any suspicion of abnormal findings should result in the initiation
of an appropriate examination and removal from the match or training session (if any orange
flags are identified as per Table 4 ). Remember that orange flag signs can always turn into red
flags requiring emergency management. Only if players have no suspected signs or symptoms of
concussion or any other significant injury (i.e. only if no orange flags are identified) should they
be allowed to continue to play or train.

The post-match examinations serve to establish a diagnosis so as to accurately initiate therapeutic

strategies and enable a safe return to football. The physician should be aware that an emergency
situation can arise at any time in the hours and days immediately after the head injury; therefore,
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repeated comprehensive examinations are required. Ideally, the team physician should know each
individual player, including their characteristics, medical history and baseline test results (if such
tests have been performed), and should be able to communicate with all players appropriately.

Observation and recognition (Phase 1)

Team physicians should observe the match (or training) with a focus on potential head injuries,
which often happen during aerial duels, and specifically the immediate red and orange flags, such
as (suspected) loss of consciousness, convulsion or abnormal posturing, slowness or imbalance.
The injury mechanism and player behaviour are best recognised using direct observation –
supported, if possible, by immediate video review. There are specific signs following a head
injury that should increase the suspicion of concussion (Table 1). If there is access to video review,
there are relevant recommendations that can assist with the approach (Table 2).

Table 1. Observable signs of concussion (adapted from Davis GA, Makdissi M, Bloomfield P, et al.
2019)

Lying motionless Lying without purposeful movement on the playing surface for >2 seconds.* The player does not appear
to move or react purposefully, respond or reply appropriately to the game situation (including team-mates,
opponents, match officials or medical staff). Concern may be shown by other players or match officials.

(* >2 seconds is the threshold for removal and assessment of the player. Significantly longer periods of lying
motionless may necessitate immediate and permanent removal from play, depending on the circumstances.)

Motor
incoordination The player appears unsteady on their feet (including losing balance, staggering/stumbling, struggling to get
up or falling) or in the upper limbs (including fumbling). May occur when the athlete is rising from the playing
surface or in the motion of walking/running .

Impact seizure Involuntary clonic movements that comprise periods of asymmetric and irregular rhythmic jerking of axial or
limb muscles.

Tonic posturing
Involuntary, sustained contraction of one or more limbs (typically upper limbs), so that the limb is held stiff
despite the influence of gravity or the position of the player. Other muscles, such as the cervical, axial and
lower-limb muscles, may also be involved. Tonic posturing may be observed while the player is on the playing
surface or in the motion of falling, where the player may also demonstrate no protective action.*

(*This was previously known as “no protective action ­– stiff”.)

No protective The player falls to the playing surface in an unprotected manner (i.e. without stretching out their hands or
action arms to lessen or minimise the fall) after direct or indirect contact to the head. The player demonstrates loss
– floppy of motor tone (which may be observed in the limbs and/or neck*) before landing on the playing surface.

(*When the player’s arms are being held by a tackling opponent, this may only be observed in the neck, which
was previously known as “cervical hypotonia”.)

Blank/vacant The player exhibits no facial expression or apparent emotion in response to the environment.*
look
(*This may include a lack of focus/attention of vision. A blank/vacant look is best appreciated in reference to
the athlete’s normal or expected facial expression.)
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Table 2. Six key video-review steps for the team clinician (adapted from Patricios JS, 
Ardern CL, Hislop MD, et al. 2018)

1 Look for the suspected head impact event

Look for the immediate Does the player fall to the ground? If the player falls, is there loss of head and
2 response of the injured player neck control? Does the player protect themselves when falling? If the player remains
(0-2 seconds) upright, are they steady on their feet?

If the player falls, do they move spontaneously? Is there evidence of purposeful

voluntary movement (i.e. placing the ball or completing a tackle)? Is there evidence
of a concussive convulsion or tonic posturing? How does the player respond to
Look for the subsequent
3 the attending medical staff (this phase may extend for substantially longer than
response (2-5seconds)
5 seconds, particularly if in-line cervical immobilisation is required)? If the player
remains standing, the distinction between the subsequent and late responses may
be unclear.

Watch for the player’s late

Is the player unsteady when attempting to get to their feet and return to sport?
response when returning to
4 Does the player need help from others to stand up? Are the player’s movements fluid
their feet (if the athlete has
and coordinated? Does the player fall to the ground?
fallen)

Watch the player’s behaviour Are their actions appropriate or not? Do they move immediately to the correct
5
on returning to sport position on the pitch?

6 Observe the responses of other players and match officials

Emergency management and red flags for referral to hospital

Prior to the initial examination, it is important to consider the differential diagnoses of a

deteriorating or collapsed player. Potentially life-threatening emergency concerns after an acute
head injury include signs or symptoms of cardiopulmonary arrest or of severe structural injuries
to the brain, skull, face, cervical spine or spinal cord, which have been denoted as “red flags”.
The emergency assessment and management after any acute head injury should be performed
according to clear principles and standardised practice, as per the FIFA Emergency Medicine
Manual.

Any head injury should be regarded as having a concomitant cervical spine injury until this
has been excluded by clinical examination, or by imaging if indicated (Table 3). Any suspicion
of a cervical fracture or intraspinal lesion (e.g. as prompted by a Glasgow Coma Scale  score
FIFA Medical Concussion Protocol

<15 on initial assessment, neck pain or tenderness, focal neurological deficit, paraesthesia or
weakness in the extremities, or any other clinical suspicion of cervical spine injury) should result
in immobilisation and stabilisation of the cervical spine, appropriate removal from the pitch and
emergency transport to a hospital.

Any suspicion of a skull fracture should result in immediate removal from play. In addition to local
ocular tenderness to palpation, other significant signs and symptoms of an orbital floor fracture
are periorbital haematoma, double vision (diplopia) and abnormalities in eye movements. Any
deterioration of signs and symptoms can indicate intracranial bleeding and/or swelling, which
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can only be diagnosed by tomographic imaging (e.g. computerised tomography) of the brain.
Therefore, it is also important to continuously observe players even if they are initially symptom-
free.

Table 3: Emergency management principles (from FIFA Emergency Medicine Manual)

Concern (C),
Domain Actions Consequence
Examination (E)

- Start cardiopulmonary resuscitation (CPR) Remove the player

chain: emphasis on chest compression and rapid from the pitch and
defibrillation. continue emergency
- Place the automated external defibrillator management if
C: Cardiopulmonary arrest
(AED) but shock the player only if the AED indicated.
Cardiopulmonary

E: Unresponsiveness, not
device self-charges and verbally recommends
breathing normally
pressing the shock button. Consider immediate
- Place the player onto a spinal stabilisation emergency transport
device (e.g. spinal board) and strap to hospital.
appropriately.

C: Intracranial lesion
E: Glasgow Coma Scale
- Neutralise and stabilise the cervical spine
score
appropriately.
<13/15, loss of
- Maintain and protect the airway as safely as
consciousness, severe
possible.
headache, repetitive
- Ventilate the unconscious patient if necessary.
vomiting, seizure/convulsion,
- Place the player onto a spinal stabilisation
abnormal posturing, new
device (e.g. spinal board) and strap
difference in pupil size,
appropriately.
nystagmus, fall due to
Brain

imbalance

C: Fracture - Neutralise and stabilise the cervical spine

E: Severe headache, blood appropriately.
Skull and face

or clear fluid exiting from - Control any external bleeding.

the ear(s) or nose, deformity, - Place the player onto a spinal stabilisation
periocular or retroauricular device (e.g. spinal board) and strap
haematoma appropriately.

C: Fracture or intraspinal - Neutralise and stabilise the cervical spine

Cervical spine

lesion appropriately.
E: Deformity, severe pain, - Place the player onto a spinal stabilisation
and neck

swelling over the neck, device (e.g. spinal board) and strap
paresis, impaired sensation appropriately.
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Initial (on-pitch) examination of head injuries (Phase 2)

The outcome of the initial (on-pitch) examination is the basis for the team physician’s decision
on emergency management, referral to hospital, removal from play and/or off-pitch assessment
in a quiet area. The physician’s decision should be communicated to the referee and the coach.

The recommended elements of the initial inspection and examination are based on the latest
version of the Sport Concussion Assessment Tool (currently SCAT5 ) and the National Institute of
Health and Care Excellence (NICE) criteria (Table 4). During this initial examination, it is essential
to focus on red and orange flags.

The inspection concentrates on visible signs (e.g. loss of consciousness, vomiting, mechanism
of injury), while the examination assesses core signs and symptoms of neurological impairment
of different brain areas (cortical, subcortical, cerebellar, brain stem) and of a cervical spine or
intraspinal injury. Any period of loss of consciousness or a Glasgow Coma Score <15 indicates
a brain injury. At any stage during this initial examination, the medical personnel attending
to the injured player can utilise information/assistance from other available resources, such as
video-replay technology or eyewitness accounts. The procedures for all of these, as well as the
relevant lines of communication, should be agreed pre-match/training and documented in the
FIFA Emergency Action Plan.

In non-emergency situations, the injured player should be removed to the off-pitch location for
further assessment in either of the following scenarios:
The outcome in one or more aspects of the initial assessment is considered or suspected to be
abnormal and additional time for examination is required.
All tests yield normal results, but the team physician suspects that the player is suffering from
functional neurological impairment.

If there is no evidence of red or orange flags and the team physician’s on-pitch assessment is
not concerning, with the inspection and examination being normal, the team physician should
continue to observe the player throughout the match and re-evaluate them serially to watch for
the delayed onset of signs or symptoms (Phase 5). All players who have suffered a head injury
should be observed for the first 24 hours thereafter (Phase 6).
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Table 4: Initial (on-pitch) examination of a head injury

1 Acute signs
Short-term loss of consciousness No Yes
Deformity or swelling of the head or neck or holding of the head due to
Inspection

No Yes
pain/for stabilisation
Blood or clear fluid exiting from the ear(s) or nose No Yes
Blank look No Yes
Slowness in getting up No Yes
Vomiting No Yes
Uncharacteristic behaviour No Yes
2 Glasgow Coma Scale: 15 points
Eye opening: spontaneous (4 points) Yes No
Verbal: oriented (name, place, date) (5 points) Yes No
Motor: obeys commands (6 points) Yes No
3 Selected new acute symptoms
Headache or pressure in the head No Yes
Neck pain No Yes
Nausea No Yes
Vertigo, dizziness, drowsiness, unsteadiness No Yes
Blurred or double vision, sensitivity to light No Yes
Tinnitus, hypacusis, hyperacusis No Yes
Impaired sensation in the upper or lower extremities No Yes
4 Orientation and memory (Maddocks questions)
What venue are we at today? Correct Incorrect
Examination

Which half of the match is it now? Correct Incorrect

Who (which team) scored last in this match? Correct Incorrect
Which team did your team play last week/match? Correct Incorrect
Did your team win the last match? Correct Incorrect
5 Delayed, slow or inappropriate responses No Yes
6 New difference in pupil size, crossed eyes, spontaneous nystagmus No Yes
7 Range of motion of the cervical spine, only if no acute neck pain
Normal and Impaired or
Active rotation to the left and right from a neutral position
painless painful

Normal and Impaired or

Active flexion and extension from a neutral position
painless painful
8 Strength of the upper and lower extremities Normal Impaired
9 Touch sensation of the upper and lower extremities Normal Impaired
10 Balance, control and coordination of posture and the limbs
Stand on both legs with heel and toe together Stable/no
Failed
(eyes closed, 10 seconds; if failed, maximum 1 repetition) sway

Finger-to-nose task (right and left) All trials

Failed
(eyes closed, 2 repetitions, both sides) correct

If no signs or symptoms -> player allowed to return to match play or training; further observation until leaving the
sports facilities

Orange flags can turn into red flags.

If any orange flag or if the physician is in doubt -> emoval from football and further examination

If any red flag -> emergency management

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Off-pitch examination (Phase 3)

The off-pitch examination should focus on red and orange flags (Table 5). Testing of ocular
motor function should be included, since many of the pathways in the brain potentially affected
by head injuries are involved in ocular motor control. Obvious minor injuries, such as lacerations
or bruises, might be treated.

Table 5: Selected signs and symptoms indicating red and orange flags after a head injury

Domain Red flags Orange flags

Signs: Glasgow Coma Scale score 13/15 or 14/15,

blank look, confusion, disorientation,
Alertness/ delayed, slow or inappropriate response,
Glasgow Coma Scale score <13/15 difficulty concentrating or remembering
attention
Symptoms: Feeling slowed down, “don’t feel right”,
drowsiness, fatigue, “low energy”

Seizure/convulsion or postictal signs, Signs: Impaired control of trunk or limb movements

Neuromotor
abnormal posturing

Signs: Nausea or vomiting (once), holding of the

Headache Severe headache, repetitive vomiting head
Symptoms: Pressure, headache

Signs: Imbalance
Dizziness/balance Fall due to imbalance
Symptoms: Vertigo, dizziness, fogginess, unsteadiness

Crossed eyes, nystagmus, other Symptoms: Blurred vision, “eyes cannot follow”,
Vision/ocular acute disordered eye movements, sensitivity to light
motor function new difference in pupil size

Signs: Emotional instability, irritability or aggression

Emotion/ with little or no provocation
behaviour

Hearing Acute hearing loss Symptoms: Hyperacusis, hypacusis, tinnitus

Pain, tenderness, swelling, Signs: Impaired hearing, tinnitus, sensitivity to noise

Cervical spine/ deformity, paresis, impaired
spinal cord sensation in the upper or lower
extremities Symptoms: Neck pain

Blood or clear fluid exiting from the

Signs: Contusion, laceration
Skull/face ear(s) or nose, deformity, periocular
or retroauricular haematoma
FIFA Medical Concussion Protocol

Personal history Anticoagulation, clotting disorder Previous brain injury

Note: some signs and symptoms can be attributed to different domains. Orange flags can turn into red flags.
RED FLAGS: Potential life-threatening problems or hints of intra- or extracerebral lesion
-> if any: emergency management and consider immediate transport to hospital
ORANGE FLAGS: Neurological or orthopaedical impairment
-> if any or the physician is in doubt: removal from football and further examination, with a specialist
to be consulted if required
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Quiet-area examination and treatment (Phase 4)

If any (suspected) orange flags are identified during the initial on- or off-pitch examination, the
player should be examined in the medical room using the latest version of the Sport Concussion
Assessment Tool (SCAT5) and a detailed neurological examination.

The neurological examination should include an examination of cranial nerves, vestibular, balance
and coordinative functions (spontaneous nystagmus, head impulse test, vertical eye deviation,
dynamic visual acuity, balance (Romberg), positioning manoeuvres), the cervical spine (range of
motion, stability, proprioception, strength, muscle tone), the motor function of the upper/lower
extremities, and standardised neurocognitive tests. Based on the outcome of the neurological
examination, the team physician may decide on further examinations, as recommended by NICE
for head injuries and by the European Federation of Neurological Societies guidelines for mild
traumatic brain injuries, as well as other validated guidelines.

Players who continued playing or returned to the match in which they incurred the head injury,
and who have no further signs or symptoms after Phase 2 (or 3), can be allowed to participate as
usual in the next training session and match.

Players who are  removed  from a match or training session and  have signs or symptoms  of a
traumatic brain injury or of another significant head injury at any time should complete the
Graduated Return-to- Football Programme (Phase 8) once their symptoms have resolved.

Observation and serial re-examination until departure (Phase 5)

The team physician should observe the player until the end of the match for worsening or
additional signs or symptoms, regardless of whether the player has returned to or been removed
from match play. Medications that may mask or worsen symptoms should be avoided unless a
more severe head injury has been ruled out. Any worsening or newly developed signs or symptoms
should result in emergency management in the case of red flags or further examinations in the
case of orange flags.

Prior to leaving the sports facilities, all injured players should be re-examined for worsening
or new signs and symptoms using the latest version of the Sport Concussion Assessment Tool .
Before travel without access to emergency care (e.g. flights), any worsening symptoms regarding
any form of brain, skull or cervical spine injury should be checked, and any concerns allayed,
using appropriate diagnostic imaging.

An initial computerised tomography scan is recommended on the day of the injury if any of the
following are present:

• Glasgow Coma Scale score <13 (or <15 after 2 hours)

• Suspected skull fracture
• More than one episode of vomiting
• Post-injury seizure
• Loss of consciousness
• Persistent anterograde amnesia
• Focal neurological deficit
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Observation for 24 hours after head injury (Phase 6)

In general, all players who have suffered a head injury should be observed for 24 hours either
by the team physician or by a responsible adult instructed to immediately contact the team
physician or the emergency department of the closest hospital in the event of worsening or
new symptoms (red or orange flags). Until re-evaluation (Phase 7), physical and cognitive rest is
recommended, which includes avoiding the use of electronic devices.

If a player was allowed to return to play on the day of the injury and is free of symptoms, and
the neurological examination does not show anything abnormal, the team physician may decide
that the observation is not necessary. In any case, the injured player should be informed and
instructed to report worsening or new symptoms, and the team physician should contact the
player the following morning with respect to symptom development and further steps. Brain
injury advice cards should be issued if appropriate – an example is shown below.

CONCUSSION INJURY ADVICE

Clinic phone number:_________________________

(To be given to the person monitoring the concussed athlete)

Patient’s name:_______________________________
This patient has received an injury to the head. A careful medical
examination has been carried out and no sign of any serious complications
has been found. The recovery time is variable across individuals and the Date/time of injury:_ __________________________
patient will need monitoring for a further period by a responsible adult.
The treating physician will provide guidance as to this time frame.
Date/time of medical review:____________________
If you notice, or the patient notices, any change in the patient’s behaviour,
vomiting, worsening headache, double vision or excessive drowsiness, Healthcare provider:
please telephone the patient’s doctor or the nearest hospital emergency
department immediately.

Other important points for the athlete to bear in mind:

Initial rest: limit physical activity to routine daily activities (avoid exercise,
training, sport) and limit activities such as school, work and screen time to
a level that does not worsen symptoms.

1) Avoid alcohol.
Adapted from Concussion in Sport Group 2017
2) Avoid prescription or non-prescription medications without medical
supervision. Specifically:

a) Avoid sleeping tablets.

FIFA Medical Concussion Protocol

b) Do not use aspirin, anti-inflammatory medications or stronger pain

medications such as narcotics.

3) Do not drive until cleared by a healthcare professional.

4) Any return to play/sport requires clearance from a healthcare

professional.

Contact details or stamp

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Re-evaluation between 18 and 72 hours after head injury (Phase 7)

Players who were removed from football, or who continued to play and developed specific signs
or symptoms at any time after the head injury, should be re-evaluated within 72  hours by a
physician who is experienced in head injury assessment.

The time frame of up to 72 hours has been chosen because symptoms can develop with latency and
a brief initial period of cognitive and physical rest after a brain injury is currently recommended.
The team physician should assess the injured player daily during this period if the number or
intensity of the signs and symptoms do not improve or even worsen.

In addition to the examination of cranial nerves, the cervical spine, the motor function of the
upper/lower extremities, balance, vestibular and ocular motor functions, vision, coordination,
emotions and neuropsychological tests, a detailed medical history (e.g. previous head injuries,
pre-existing headache or sleep problems) – and, if indicated, neurocognitive tests – should be
included. These examinations provide valuable hints, in conjunction with the baseline tests, that
can assist with different head injury diagnoses.

The aim of the examinations in Phase 7 is to decide on the next step:

In the event of no, minimal or improving symptoms and a normal outcome in all examinations
in Phase  7, the player can be medically cleared to  start the Graduated Return-to-Football
Programme (Phase 8).

In the event of persistent orange flags, the player should be referred to a medical specialist for
further examination and treatment.

Graduated Return-to-Football Programme (Phase 8)

The Graduated Return-to-Football Programme (Table 6) is based on the protocol drawn up by

the Concussion in Sport Group and intended to ensure a controlled, stepwise return to sports
activities for high-level adult football players after concussion/traumatic brain injuries. For
players with structural damage (such as intracranial haemorrhage or a skull fracture), the return-
to-football procedure should be determined on an individual basis by the physician in charge.

The player should be re-examined by the physician in charge before starting symptom-limited
activity (Stage 1), ideally within 18-72 hours after the head injury (Phase 7), and before returning
to “routine/contact training” (Stage 5). The medical re-evaluations should focus on:
Abnormal diagnostic findings on the day of the injury
Persistent or additional signs or symptoms or changes in their character, intensity or frequency
Symptom development under an increasing physical and cognitive training load

Current guidelines and position statements agree that a player with a (suspected) concussion
should not return to sport on the same day. An initial phase of cognitive and physical rest (24
to 48  hours) is recommended before the graduated return to training and match play. After
this initial period of rest, low-level exercise that does not heighten the pre-exercise intensity
of symptoms or lead to new symptoms has been identified as beneficial. Allowing a player to
participate in low-level exertion without an exacerbation of symptoms and without the risk
of contact or a fall may also minimise the player’s likelihood of emotional dysregulation as a
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psychological response to the injury. The period required until a return to match play varies
and might be influenced by the player’s age or history. A  multidisciplinary-team approach is
recommended, especially with respect to the return to routine/contact training.

The Graduated Return-to-Football Programme comprises six stages with a progressive increase
in physical demands (“aerobic” to “anaerobic”, “no resistance” to “resistance”), football-specific
exercises (“simple” to “complex”), and the risk of contact (“individualised” to “team training”,
“non-contact” to “full contact”) and head impact (“no heading” to “heading”). Each stage
should include at least one training session and last a minimum of 24  hours.  In the event of
worsening or recurring symptoms during or after a training session at any stage, the player
should rest until these symptoms have resolved (for a minimum of 24 hours) and then continue
the programme at the previous symptom-free stage. The player should only be medically cleared
to return to match play when each stage has been completed without symptoms. With younger
players and players with certain risk factors, such as a history of repetitive concussive injuries, a
more conservative approach must be followed.

The Accelerated Return-to-Football Programme should only be initiated if (a) any acute post-
injury symptoms and signs were classified as not specific to concussion, (b) these unspecific
symptoms and signs lasted for under 24 hours, and (c) the results of the re-evaluation were
normal (or similar to the pre-injury baseline, if baseline tests were performed). A player is not
eligible for an accelerated return to football in the event of persistent orange flags or one or
more red flags at any time after the head injury. The accelerated approach focuses on stages 2
and 5 and requires close cooperation between the player, the coach, the team physician (who
should be experienced in concussion management) and FIFA Medical.

Medical clearance for a return to football should always be given by the treating physician and
be based on medical considerations only, regardless of a player’s desire to play, the dissimulation
of symptoms and/or pressure from others including the coaching staff, parents or the media.

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Table 6: Graduated Return-to-Football Programme for high-level players

STAGE FOCUS ACTIVITY
Symptom-limited Daily activities without exaggeration of symptom threshold (worsening of pre-activity symptoms or additional
1 activity symptoms), e.g. 10 minutes of slow walking
Light aerobic a) Cardiovascular exercise on stationary bike; 25-40 minutes including warm-up and cool-down; controlled
exercises activities, low-to-moderate intensity
2
(unspecific) b) Mobility/stretching, stabilisation and balance (double- and single-stance) exercises

a) Cardiovascular training on the pitch

- Warm-up for 10 minutes at moderate intensity with variable running tasks
- Interval runs at higher intensities with sufficient breaks
- Cool-down for 5-10 minutes at low intensity
b) Technical training with the ball (1:1)
- Basics: balance and passing; short/long passing; easy shooting at targets
Football-specific c) Body training (no resistance/add elastic resistance)
3 exercises - Mobility and stretching exercises
- Trunk strength/stabilisation exercises (no resistance; no explosive movements)
- Basic lower-/upper-extremity strength exercises (elastic resistance)
- Balance exercises (double- and single-stance) on unstable surfaces
No heavy-resistance training, no contact activities
For goalkeepers: controlled diving movements (not explosive) on a foam surface in the gym (without
catching the ball)

a) Cardiovascular training on the pitch

- Warm-up for 10 minutes at moderate intensity with straight running, changes of direction, lateral shuffles,
forward-backward running, zigzag running
- Interval runs at high intensity up to 90% HR max
- Cool-down for 5-10 minutes at low intensity
b) Technical training (with a small group of players)
- Small-sized game
- Short/long passing
- Shooting at goal/targets
- Plant and cut, dribbling with the ball
- Basics: easy heading with only a soft ball (increase in complexity: while balancing), controlled setting and
Non-contact limited quantity
4.1 football training c) Body training (including elastic resistance)
drills - Mobility and stretching exercises
- Trunk strength/stabilisation exercises (including free weights)
- Basic lower-/upper-extremity strength exercises (elastic resistance, free weights)
- Balance exercises (double- and single-stance) on unstable surfaces
d) Strength training
- Keep resistance below about 80% 1-RM, no Olympic weightlifting or exercises with the head below the
level of the hips
- Progressively increase external resistance for multi-joint exercises
No contact activities
For goalkeepers: diving drills on a foam surface, some without catching the ball and others with catches
(shots from short/medium range; 1:1 with the goalkeeping coach)

Controlled contact activities: simulate controlled contact situations (e.g. headers, checks, tackles)
- Stepwise increase in intensity
- From playing with 1 partner (e.g. rehabilitation coach) to training in small groups of players
Football training - Increase from a small playing area (1/3, 1/4) to the whole pitch
4.2 drills with - Heading with a regular ball in controlled settings (e.g. after throwing the ball; heading without opposition);
controlled contact gradual increase in the number of headers
For goalkeepers: controlled diving drills on grass, some without catching the ball and others with catches
(shots from short/medium/long range; 1:1 with the goalkeeping coach)

Following medical clearance, which should ideally be issued by a multidisciplinary team, participation in
Full-contact normal team training
5 practice (team a) Cardiovascular training: continue to progress
training) b) Body and strength training: resume usual routine training (unrestricted)
c) Assess and ensure psychological readiness

Return to Normal match play

6 competitive
football
Note: only move to the next stage when activities are tolerated without any worsening of pre-activity symptoms or the emergence of additional
symptoms. Abbreviations: HR max = maximum heart rate; 1-RM = one-repetition maximum.
 #SuspectAndProtect 15

Summary

Head injuries can result in different outcomes, and signs and symptoms can develop or change
rapidly within the minutes, hours and days after a head injury. Concussion can manifest itself
72 hours after the initial injury. Therefore, a systematic procedure for the examination and
management of football players after head injuries should be implemented to support team
physicians in their decision as to whether a player should be allowed to continue to play or
should be removed. Awareness of the potential severity of head injuries should be raised across
sports and medical professionals.

FIFA Medical Concussion Protocol

16 #SuspectAndProtect

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